Peripartum Cardiomyopathy
Abstract & Commentary
Synopsis: Subsequent pregnancy in women who had peripartum cardiomyopathy results in further decreases in ejection fraction, and increased morbidity and mortality.
Source: Elkayam U, et al. N Engl J Med. 2001;344:1567-1571.
Although considered rare, consulting cardiologists at medium sized institutions see a case of peripartum cardiomyopathy about once every 1-2 years. Most of these unfortunate individuals recover, as the prognosis for this form of cardiomyopathy is one of the best.1 Thus, the issue of the risk of subsequent pregnancies in these patients is an issue. Accordingly, Elkayam and colleagues surveyed 44 women and their physicians who had peripartum cardiomyopathy and a total of 60 subsequent pregnancies. The diagnostic criteria for peripartum cardiomyopathy was heart failure occurring during the last 6 months of pregnancy or the first 6 months after pregnancy termination, without another identifiable cause, and ejection fraction (EF) < 40%. The diagnosis of cardiomyopathy was made most frequently in the first month after delivery (28 women). Interestingly, 10 women had preeclampsia. Most of the women had 1 subsequent pregnancy, but 11 had up to 3 additional pregnancies. At diagnosis, the EF for the entire cohort was 32%, which increased to 49% before the first subsequent pregnancy (P < .001) and was 42% during the first subsequent pregnancy (P < .001). After the first pregnancy, 28 women had an increase in EF to > 50% (group 1) and 16 did not (group 2). During the subsequent pregnancy, both groups experienced a decrease in EF and an increase afterward to a level lower than the first postpartum follow-up. Heart failure symptoms during the first subsequent pregnancy occurred in 21% of group 1 and 44% of group 2. Mortality was zero in group 1 and 19% in group 2. Also, the risk of premature delivery or therapeutic abortion was higher in group 2. Elkayam et al concluded that subsequent pregnancy in women who had peripartum cardiomyopathy results in further decreases in EF and increased morbidity and mortality.
Comment by Michael H. Crawford, MD
Despite the fact that this is a retrospective survey study, it is the largest reported experience with peripartum cardiomyopathy, and the results are largely consistent with previous smaller studies. Perhaps the biggest surprise is that the outcomes in these women were not as bad as one might expect based upon older studies. The mortality over a 7-year follow-up was 7%, and all the deaths were in the group with persistent left ventricular systolic dysfunction. Perhaps this better outcome is due to improved recognition and treatment of heart failure today or it could be due to the relatively high rate (20%) of therapeutic abortions of the subsequent pregnancies. The women who did not have abortions had a worse prognosis than those who did, especially in group 2.
The most important clinical message from this study is that overt heart failure and further reductions in EF with subsequent pregnancies occurred in both groups. Thus, a return of EF to normal after the first pregnancy complicated by peripartum cardiomyopathy did not eliminate the possibility of future bad outcomes. Although death was only observed in the persistent low EF group, 21% of the normalized EF group had symptomatic heart failure with a subsequent pregnancy, and 21% had a > 20% decrease in ejection fraction. Why a subsequent pregnancy is associated with a return of left ventricular dysfunction in women whose function had returned to normal is unknown. Perhaps they have subclinical ventricular dysfunction that the increased preload and demands for cardiac output of pregnancy unmask. If this is the case, then the admonition that they avoid further pregnancies makes physiologic sense.
Finally, it should be mentioned that fetal health appeared to be compromised by subsequent pregnancies as well, especially in group 2 where there was a high rate of premature deliveries (50%). However, there was no perinatal mortality in either group. Elkayam et al correctly point out that women need to be cautioned about these risks if they are considering subsequent pregnancies following the diagnosis of peripartum cardiomyopathy.
Reference
1. Felker GM, et al. N Engl J Med. 2000;342:1077-1084.
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